Provider Demographics
NPI:1205943057
Name:JACKSONS DRUGS OF MONTICELLO INC
Entity type:Organization
Organization Name:JACKSONS DRUGS OF MONTICELLO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:850-997-3553
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32345-0338
Mailing Address - Country:US
Mailing Address - Phone:850-997-3553
Mailing Address - Fax:850-342-3578
Practice Address - Street 1:166 E DOGWOOD ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-1928
Practice Address - Country:US
Practice Address - Phone:850-997-3553
Practice Address - Fax:850-342-3578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH1023183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101505200Medicaid
FL1149060001Medicare NSC